One of the least talked about problems in pandemic preparedness planning is that even if there is flu all around us and the health care system is struggling (and almost certainly failing) to handle the resulting demand of patients, people will still be getting sick from the usual things (heart attacks, strokes, etc.), having accidents, and yes, getting pregnant.
There is pretty good reason to think that getting the flu when pregnant is even worse than getting the flu otherwise. A pregnant woman's immune system reacts differently because of the special circumstance of accommodating the foreign antigens represented by the fetus. Evidence from past pandemics suggests that the risk is not only higher but very high for pregnant women during a pandemic. And this has CDC worried. Helen Branswell of Canadian Press sets it all out in a characteristically informative and well-informed piece:
Women who are pregnant when the next flu pandemic strikes will find themselves with special needs, concerns and risks -- and very little science to help decide things like whether it's safe to take flu drugs or necessary to wear medical masks in public.Recognizing this group's vulnerability, the U.S. Centers for Disease Control is gathering experts with backgrounds varying from drug metabolism in pregnancy to baby delivery to come up with special pandemic guidelines for pregnant women.
The nearly 70 experts convene in Atlanta on Thursday and Friday to go over what little data exists. In the process, they will try to figure out what to recommend on issues such as antiviral drug use in pregnant woman and how to try to ensure continuity of obstetrical care for mothers-to-be during what is expected to be a medical emergency.
An expert from the University of British Columbia who will be attending the meeting acknowledges at least some of the recommendations will not be typical evidence-based guidance, but rather advice "couched in the language of ignorance."(Helen Branswell, Canadian Press)
I want to pause for a minute and stand back and admire this reporting. The pull quote is the first 175 words of a 798 word article. Consider how much we learn in that short space. The craftsmanship here is really stunning, the more so because we are usually unaware of it.
But back to the subject. The rest of Branswell's piece supplies details about some of the topics of concern: the effects of fever on pregnancy outcome, the unknown adverse effects of prophylactic antivirals and vaccines with novel adjuvants, the extent of increased risk and how to advise and handle pregnant women during a pandemic. The problem of pregnant women is a special concern for most people because if we weren't wired to worry about the next generation we probably wouldn't have survived as a species. But in a medical, rather than an evolutionary sense, it is part of a much bigger problem: what about all the non-flu related medical problems during a pandemic . . . heart attacks and strokes, acute appendicitis, kidney stones, auto accidents, etc. It's not just a triage question for flu patients (which flu patients will be treated first, who will get respirators, etc.) but a triage question for all urgent medical cases, many of which will not be flu, even in a pandemic. We can cancel elective medical procedures but the emergency room is full of non-elective medical demands.
The fact that the medical care system is already broken should be alarming, but apparently we have gotten used to it, sort of like having a stone in our shoe. We keep limping along, ignoring the nagging pain. But if we have a pandemic we will be asked to run for our lives, not just from flu but from all the other routine things, too. Flu prepping won't protect us from those. Only an adequate health care system can do that.
By all means let's each of us do what we can individually to be ready for a pandemi. But to be really ready we are going to have to get together and invest in a public health and social service system. I don't see a lot of evidence we are doing that. At all.
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Increased expenditures for public health are impossible to obtain in the present political environment.
Neoliberalism promotes privatization of state enterprises, deregulation, and the reduction of taxes for the rich. Government must be reduced to a minimum, meaning the provision of police services and a strong military. All other expenditures by the government will deprive citizens of their economic freedom. For the government to take money from one citizen, and transfer it to another is unjust, since it attacks the economic freedom of it's citizens when it does this.
All services for health care should be privatized. Those who cannot pay for those services should receive referral to charitable organizations.
I do not agree with this economic philosophy, but those in power do.
I agree Herman, that health model is a recipe for disaster. The rich get richer and the poor, poorer.
Here, in Australia, the government pays for basic health services for the entire nation. Those that want above basic care, a private room, choice of doctor, choice of hospital, plastic surgery and the like, pay extra health premiums through their private health insurance. Everyone in Australia has the right to basic health services. Our government, of course, encourages everyone to get some form of private health insurance. Our health system is far from perfect, however, it does work.
PS. Herman I enjoy reading what you have to say. It is always interesting.
Thanks Victoria, I also enjoy reading what you have to say.I feel great sadness to see the total disregard for human life in the United States, and see our health care system collapsing. In 2005 the top 1% of Americans earned 21.2% of all income. The free market neoliberal economic philosophy is poison to all humanity. It encourages unjust wars, as in Iraq, to steal oil, and shed innocent blood.
This excessive concentration of wealth will produce violence both internationally and within the United States, which is a corrupt empire that is imploding. How can the citizens of the world not hate us, when a US warship off the coast of Somalia, fires a missile to kill a terrorist, and instead kills and wounds innocent people?
Herman, you are in a unique position, that being, you are an American living outside of the US. You see the end results of American policies and you are able to give a different perspective on what is happening in Guatemala. There are a myriad of reasons why America is where she is - the following was my answer to EM's question last week - "Why do they hate us" (minus the small introduction). Do you agree? I am sorry, it is 3 o'clock in the morning here, I am feeling rather lazy and tired. Forgive me.
Economic
As the worlds most powerful economy, US markets are dominated by publicly traded organisations which have long since saturated the US domestic market. In order to satisfy stock owners profit expectations, the only way these companies can deliver required rate of returns is by cannibalising each others market share or by reducing costs through self cannibalisation. Obviously these are not viable ways of doing business in the medium to long term so these companies have sought market growth through international expansion this is an entirely natural progression. This expansion has been sold to the world as globalisation.
While globalisation is a fine ideal from the perspective of the dominant world players, the weaker economies have suffered with the expansion of US interests abroad (other countries can also be included but they are not seen to be as dominating as American companies). The benefits of globalisation simply do not transfer to the weaker economic communities. Not only are national sensitivities (religion, culture, etc) ignored in the dry financial analysis of global economics but there are the economic imbalances that do not permit for equitable distribution of rewards. For example, US shareholders obtain dividends from the success of globalisation but the international communities from whence some of this wealth is derived simply do not have the disposable income to participate. This generates a sense of being used.
In cases where US companies target international markets, they are usually pursued with the same gusto as marketing campaigns in the US domestic market. While most Americans would not be fazed by the ardour of this marketing, they are seen by viewers in the international markets as being very aggressive. For example, I would hazard the guess that there are possibly 1000 2000 African Americans living in Australia with a good proportion of these people totally disinterested in Hip Hop music and the culture associated with this genre. Yet the marketing of hip Hop music, the gangsta culture, its clothing, and speech is pervasive. It swamps the Australian music culture; its all over our media (newspapers, magazine, TV, radio, etc). Whilst Australia is not that dissimilar to the US in many ways, this kind marketing really gets up peoples noses.
Social.
In many parts of the work, there are numerous companies that are operated as family owned or socially responsive concerns; many of these are dominated by familial or social philosophies that encourage the spreading of wealth throughout the company in its wider social environment (for example Scandinavia). By American (or even UK/Aussie) standards they are all highly inefficient with far too many employees and way too many other inefficiencies. Their view of the world and how it should work is different to the US way, they reject your social systems and your ways of doing business. They like to be different and their own traditions. Yet, when your companies enter into their markets without the social inefficiencies identified above, the result is always the same: the efficient Western company wins. Socially concerned companies lose. As the premier Western economy du jour, you Americans are carrying the can as the major transgressor. Your dogged determination to grow your businesses internationally ignores these petty concerns there is a cost for this determination its called Anti American feeling. But dont feel too bad, youre not the first to have this kind of complaint just ask the African nations who their big hate was directed towards in the 1950s the pesky colonising Brits, of course.
And what about those Romans, or the Mongols, Alexander the Great.?
That was certainly true in my family. My grandfather lost his mother in the '17/'18 pandemics when she contracted the flu while pregnant with what would have been a younger sibling.
There are two really important issues here that are not related to healthcare economics. The first is how to care for pregnant women during the pandemic and the second and much bigger issue is how to provide care to seriously ill non-flu patients requiring hospitalization when all the beds are filled with critically ill and dying flu patients.
The pregnant patient ill with pandemic influenza is a special situation. First of all, do not get pregnant during the pandemic. This is one instance where a person in her first trimester at pandemic outbreak might reasonably consider an abortion. Non-pregnant women should use condoms, barrier methods, birth control pills, IUDs, or simple abstinence during the pandemic. Obtaining a supply of Plan B for use after unprotected sex is a poor plan but something to consider if you simply can't control yourself or get raped. Why? During the 1918 pandemic pregnant women and the unborn had the highest of all death rates of any group when they became infected with flu. Second, it could be almost impossible to get good prenatal care during the pandemic and it is very unlikely that there will be a safe hospital to deliver a baby in if you survived to do so. Assuming you found one, both the mother and infant would be at great risk of contracting and dying from influenza during the short time they were confined. I know these are hard words but they are realistic and the time for pulling punches and hedging around these issues is past.
The second case is what to do about all the critically ill patients who will require hospitalization during the pandemic when all the hospital beds are already occupied. This will be a disaster. There is no good answer. Putting these patients in temporary "inflatable hospitals" or in cots in hospital hallways will not be very effective. It is important that the very good mortality and morbidity statistics are entirely dependent upon one factor, having a setup and staffed hospital bed for that patient to be treated in. A setup and staffed bed is a defined term. It means a hospital bed in a medical center with all the medications, supplies, and facilities as well as HCWs and non-medical hospital support staff all there 24/7 and ready to do their job. In all honesty, I see absolutely no chance of there being anything like the current number of true setup and staffed beds available during the pandemic. I know that the states and feds are telling us that the number of surge beds available will add significantly to the current beds. This is not the case in my opinion. The reason is easy for anyone to see. I for one do not think the medical and drug supply supply chain will remain functional for long after outbreak, even if it remained open, the demand for common drugs and supplies during the pandemic will rapidly overwhelm the ability of manufacturers to resupply the hospitals. Second is staffing. We already have a nationwide nursing shortage. There will be many illness's and deaths among professional and non-professional HCWs during the pandemic. These same conditions will affect the critical non-HCWs who operate the hospitals and keep them running. There is no way to have a setup and staffed bed without enough staff. This does not include those who voluntarily withhold their services due to family illness, fear of illness, or other considerations. It is clear however that there will be a decrease in the numbers of setup and staffed hospital beds due to these factors rather than an increase as we are assured by our healthcare authorities.
So, there will be an astronomic increase in patient load at time when the available beds are reduced. This can only result in a disaster and a very big increase in deaths of critically ill influenza and non-influenza patients who under ordinary circumstances would be expected to survive their illness.
GW